130 Screening and Assessment 2. 37a: Time perspective (minimal future, plus a high past orientation; items 36, 37) total = 20 points 3. 25a: Family psychopathology (alcoholism, depression, and other major psychiatric illness in family member; items 23, 24, 25) total = 12 points When any (and certainly when all) of these three SAC clusters are scored positive, the index of potential lethality or self-harm is consid- ered to be increased exponentially, as this pattern of significant test- item content is considered to carry the SAC total score above that of a screening function to that of a sensitivity measure of degree of lethality. The basis for this assumption is that the existence of these known, em- pirically derived characteristics has an especially strong positive corre- lation with overt suicidal behavior. When these clusters are in evidence and scored accordingly, they provide the basis for assuming a much higher lethality of any self-harmful behaviors and, therefore, may be properly viewed as an index of self-destruction rather than self-harm. They may also be considered to indicate an immediate risk of overt self- destructive behavior rather than a long-term risk. TIME QUESTIONNAIRE A third suicide assessment technique, the Time Questionnaire (TQ), has been published and in use for more than 25 years as an assessment tool (Yufit & Benzies, 1978). The TQ represents time perspective in a more dimension-specific manner than items in SAC and is considered an im- portant additional measure in evaluating suicide potential. The lack of a future time perspective is a common (and understand- able) finding for most suicidal persons. Such a lack is viewed also as a serious form of cognitive constriction, since the development of an ex- panded long-term time perspective is reduced. Such constriction often limits also the development of hope, especially in times of stress. When future time perspective is lacking in suicidal persons, as it often is, such a focus further minimizes adaptation to change and curtails resiliency. Focus on the past (especially nostalgia) absorbs emotional energy and further limits any attention to the present or to the future. Cognitive constriction may well be related to a prominent orientation to the past. c06.qxd 8/2/04 11:06 AM Page 130 Assessing the Vital Balance in Evaluating Suicidal Potential 131 Many suicidal persons look to the past with obsessive ruminations (“Why didn’t I do this instead of that?”) or with nostalgic longings (“Those were the good old days gone forever”). When such time focus is self-absorbing, it can minimize a flexible approach, especially the ability to deal with any sudden change. Such self-absorption can also limit the development of future plans and may minimize the development of hope that current problems can be solved and trust that adaptation to change will eventually take place. Buoyancy becomes restricted. The resulting cognitive constriction may thus tend to limit the development of options in problem solving, creating feelings of being trapped, helpless, and vul- nerable. Such a sequence may seriously impair psychological equilibrium of affect and the continuation of a stable Vital Balance. The Time Questionnaire has a scoring manual and provides measures to quantify past, present, and future time orientations (Yufit & Benzies, 1978). Over the past two decades, the yield of this assessment instrument has consistently revealed that the time profiles of most persons who are suicidal are markedly different from those of persons who are not sui- cidal. The nonsuicidal person has a more positive and direct involvement in the present and future with minimal involvement in the past, while the suicidal person is usually much more involved in the past, negatively in- volved in the present, and minimally involved in the future (Yufit, 1991). In the TQ item asking the person to pick a month and year in the future, a high percentage of suicidal persons select the current month and cur- rent year, whereas the mean time projection for our control sample is eight years into the future no matter what the age of the person. ANGER, DEPRESSION, AND HOPELESSNESS Anger, especially internalized anger, often increases cognitive rigidity and limits resiliency and buoyancy and is considered still another major correlate of self-harm and self-destructive behaviors, especially when the anger is directed inward and focused mainly on oneself (Men- ninger, 1938). Depression is also usually viewed as a common correlate of a suicide- prone person but is not always present at a significant level, contrary to popular beliefs. However, when depression is severe, suicidal behavior should be considered a strong possibility. c06.qxd 8/2/04 11:06 AM Page 131 132 Screening and Assessment As mentioned, hopelessness is perhaps the most consistent and promi- nent psychological correlate associated with suicidal behavior, being cited in many studies, and is often mentioned as a very ominous sign by psychotherapists who treat known or latent suicidal persons. Thus, the presence of hopelessness, internalized anger, depression, cognitive constriction, the lack of a future time perspective, and a pre- occupation with the past comprise a clinical syndrome highly correlated with increased suicidal potential. In addition, the existence of illicit drug or alcohol abuse and/or de- pendency, a history of psychiatric disorders (especially schizophrenia and bipolar affective disorder) in the self and/or in family members, plus a history of prior suicidal attempts comprise additional major clus- ters of empirically derived suicide correlates. When such clusters are present, they are considered to add substantially to the likelihood of overt suicide attempts, along with higher levels of lethality in any subse- quent suicidal behavior. These characteristics relate more to self- destruction than to self-harm. In addition, when an interview reveals a more serious intention, with consequent lower ambivalence, including using a method with higher lethality with less reversibility and less chance to be rescued, self-destruction, rather than self-harm, is indi- cated. Ongoing pain, physical or psychological, actual or imagined, is also highly correlated with self-destructive ideation and overt suicidal behavior. Such unremitting psychache may foster increasing despair and helplessness and is often present in severe dysphoric states. As stated, the actual intention of the person adds a critical assessment variable of clinical significance to this growing diagnostic profile of sig- nificant correlations. Thus, “I really want to die, to end it all,” is much different from the desire to shame someone else or to gain attention via a carefully controlled self-harm attempt. Distinguishing intention is a critical task in assessing suicidal potential and the degree of lethality. Certainly, other factors can be related to assessing suicidal lethality and, for this reason, the total SAC score is to be considered a guideline for, a supplement to, and not a replacement of, clinical judgment. A high SAC score, especially when complemented by a low CAQ score, should offer support or confirmation of clinical judgment to hospitalize the per- son or, when contrary to clinical judgment, should indicate a careful re- consideration and examination of the judgment that has been formed. c06.qxd 8/2/04 11:06 AM Page 132 Assessing the Vital Balance in Evaluating Suicidal Potential 133 False positives in assessing self-harm/suicidal potential have been rare when the pattern of high vulnerability and low coping scores exist. False negatives, based on denial or suppression of feelings or manipulation, can complicate interpretations. Extremely high or low SAC scores should alert the clinicians to such possibilities, and more extensive interviewing plus added psychological projective assessment techniques for the pur- pose of serial assessment may be needed. While malingering is always a thorn in the task of assessment, it may be more difficult to engage in be- cause of the ambiguous nature of many of the stimuli used in projective techniques. In borderline scoring situations, where the scores are only moderately high or low, extended psychological assessment is usually indicated. Middle-range numerical scores may need to be supplemented by addi- tional explorations, such as serial assessments using additional assess- ment procedures. Such extended assessment can be represented by the concept of a Suicide Assessment Battery (SAB), which consists of a group of clinically focused assessment techniques to facilitate clinical judgment in a more comprehensive manner and to increase the sensitivity and specificity of assessing suicide potential. The SAB is used to assist such borderline, possibly false positive or false negative patterns in these specific assessment situations, and we have been developing additional instruments to comprise such an SAB. The already discussed Focused Clinical Interview, the SAC, the CAQ, and the Time Questionnaire are major assessment techniques that form a core segment of the SAB. Other projective assessment techniques include a specially devised Sentence Completion Technique, a Word Association Technique, a Draw- a-Person-in-the-Rain Technique, an Experiential Questionnaire, plus spe- cific Thematic Apperception Technique (TAT) cards that have revealed clinical promise in this assessment task, such as TAT cards 1, 3BG, 12BG, and 14. Unfortunately, the multidimensional components of suicidal behaviors may not be detected with sufficient consistency in response patterns from these latter projective techniques to merit the extensive time in- volved in administering, scoring, and interpreting these techniques on a more frequent basis. This is partly due to the inadequacy of existing scor- ing schemes specifically related to self-harm and self-destructiveness. c06.qxd 8/2/04 11:06 AM Page 133 134 Screening and Assessment The traditional projective techniques relate to general personality evalu- ations and usually do not focus on the specificity or sensitivity of assess- ing variables empirically related to high suicidal potential. We are trying to develop supplementary scoring schemes for the projective techniques for this purpose, but we may find it more productive to build new assess- ment techniques to measure the specific correlates, or we may modify existing projective techniques such as the newly developed Word Associ- ation, Sentence Completion, and Draw-a-Person-in-the-Rain Techniques, which have all yielded rich clinical data in more than 900 psychological evaluations to date. The Experiential Inventory, which is a listing of positive and negative experiences in the past, present, and future time perspectives, has also proven to be a useful assessment technique, and is modified from concepts of Cottle (1976). So-called suicide sub-scales, such as those derived from the MMPI, have not been found to be consistently useful, perhaps because major psychological correlates of self-harm are not being tapped. Other pub- lished personality questionnaires have not yet achieved widespread ac- ceptance, with the exception of Beck’s measures of depression, suicide ideation, and hopelessness (Beck, Kovacs, & Weissman, 1975). Most of these questionnaires lack both focus and comprehensiveness considering the complexity of assessing suicide potential. Furthermore, self-report instruments may not allow significant clinical judgments of observing the demeanor of the patient more directly by asking for specific elabora- tions to responses via an inquiry following the administration. The nature of projection, in the associations of response patterns on projectives techniques, can also provide data to examine the intentionality of the respondent, based on measures of impulsivity, constriction, inten- sity of focus, and the continuity or pervasiveness of the focus given in the response patterns. The ambiguity of the stimuli of the projective tech- niques can provide a greater in-depth exploration of intention despite the subjectivity of such interpretations. PROBLEMS AND LIMITATIONS As mentioned, sometimes patients have a desire to “look good” or to “look bad.” Manipulation and denial are important factors that need to be identified when they are present, as they will often alter the truthful- ness and validity of the response. c06.qxd 8/2/04 11:06 AM Page 134 Assessing the Vital Balance in Evaluating Suicidal Potential 135 Asking the same question in a different form or at a later juncture of the interview allows some evaluation of the consistency (or reliability) of a questionable earlier response and is one method of assessing fabrication attempts by the patient. As the saying goes, “The good thing about telling the truth is that you don’t have to remember what you said.” A very high SAC total score needs to be examined closely, although it would take a psychologically sophisticated patient to know the “right” answers to gain a very high score because most SAC items usually do not have an obvious right or wrong answer. Yet, an extremely high or low score on either the SAC or the CAQ may need further exploration to as- certain possible attempts at fabrication. Another limitation of these assessment techniques is that they may not always provide valid data with certain special populations, such as the grossly psychotic, the severely intellectually retarded, or organically impaired patients. Such conditions most likely limit the understanding and processing of the questions being asked, and these limitations need to be taken into account in making the assessment. Patients under the age of 14 may have some limitations of life experiences, which might make the CAQ score difficult to interpret for this younger age range. There is no upper age-range limitation for using the SAC or CAQ, aside from the geriatric patient with severe organicity, who is often char- acterized by serious cognitive constriction, even without an existing depression. Such constriction could limit understanding and affect re- sponse variance. Yet, this very factor of constriction often contributes to suicidal ideation and to subsequent suicide attempts and completed sui- cides among the elderly. Life-threatening physical illness, especially with ongoing pain, also constricts outlook and serves as a reality-distorting influence. Such per- sons often have a desire to consider death as the only solution to end their decline in all functions, as well as a way to end physical and/or psycholog- ical pain. The FCI should be conducted by a clinician with adequate experience to gain sufficient rapport so that detailed response data are elicited. The lack of adequate rapport and response data may dilute the accuracy of the scoring of both the SAC and the CAQ and also reduce the sensitivity and the specificity of the measures. A candid and cooperative patient is especially helpful to facilitate the elicitation of relevant response data to score the CAQ, which is more c06.qxd 8/2/04 11:06 AM Page 135 136 Screening and Assessment complex to score, as well as to elicit sufficiently elaborate patient re- sponse content. Areas assessed by the CAQ may require more time to explore than the usual interview format allows, so extended time may be needed to complete the administration of the CAQ. Depressed, withdrawn, and hostile patients usually test the limits of even the skilled clinician who is attempting to collect sufficient perti- nent response data for the scoring of any of the assessment procedures, but especially for the CAQ. In-depth interviewing is usually needed to uncover the underlying psychodynamics of such patients, and much more time is needed to gain an adequate response database. The desire to suppress suicidal intent is a common occurrence that can pose an assessment problem, but the use of the variety of assessment techniques proposed, especially those using indirect questions as projec- tive stimuli, should elicit enough pertinent response data to allow the un- covering of such hidden intentions in a more effective manner than the use of the clinical interview alone. Using an SAB as a multilevel serial assessment strategy is advantageous in more complex screening and diag- nostic situations. The factor of added time for administration, scoring, and interpretation, plus integration of the conflicting response date, must be considered, but this may be needed to ensure an adequate database for making a valid and reliable assessment. APPLICATIONS The pairing of a high SAC score and low CAQ score is usually an indica- tion for hospitalization, even if psychosis is not present. The Vital Balance is most likely impaired, and vulnerability to stress is probably high. A high SAC and high CAQ score is an indication that there may be some coping skills for managing the existing vulnerabilities, and interven- tion with outpatient psychotherapy might be sufficiently adequate treat- ment, although positive responses to the cited SAC cluster item groupings could still suggest the need for hospitalization regardless of the total SAC score. A low SAC score and a low CAQ score might suggest the need for some counseling to increase coping abilities, whereas a low SAC score and a high CAQ score would be optimal for a desirable Vital Balance of good mental health and well-being. The response data derived from the SAC and CAQ can be useful in the treatment process. The nature of c06.qxd 8/2/04 11:06 AM Page 136 Assessing the Vital Balance in Evaluating Suicidal Potential 137 specific responses or response patterns can often be used as the basis for further explorations in subsequent psychotherapy sessions, and such re- sponse data has provided important information for establishing treat- ment plans and strategies. Attempts to develop a more defined and meaningful future time per- spective have often been found very helpful in the treatment of suicidal persons, especially when there are obsessions with the past that need to be diluted, if not eliminated, so that a person can deal more fully with the present and make plans for the future. Setting reachable goals should be attained more easily and will help develop confidence and self- esteem. By doing so, the reestablishment of the equilibrium between coping and vulnerability needed for the Vital Balance is facilitated. CURRENT VALUE AND NEEDS The advent and prominence of managed care have resulted in a dramatic restriction in the utilization of inpatient psychiatric services. In fact, managed care gatekeeping models, utilization review protocols, and the emphasis on short-term outpatient treatment, as well as inpatient treat- ment, place increasing pressure on clinicians to justify the efficacy of any treatment plan. Furthermore, the role of managed care in the decision-making pro- cess often means that decisions about the level of care can depend on balancing cost containment needs against a clinician’s often subjective interpretation of clinical data. Admission for inpatient care, length of stay, and continuation of treatment are often dependent on the clini- cian’s ability to articulate and document medical necessity. Medical ne- cessity typically means that a patient’s clinical condition represents so severe an illness and impairment that hospitalization and professional treatment are needed. The impairment is usually symptom based. One such impairment is that the person is either a danger to himself or her- self or to someone else, so some form of intervention (diagnosis and pertinent treatment) or protection (hospitalization) is necessary imme- diately. Establishing medical necessity is a major requirement for third- party (insurance) reimbursement. Instruments such as the SAC and CAQ that can empirically document the degree of vulnerability and of available coping skills should help evaluate the need for hospitalization and degree of suicide risk, and they c06.qxd 8/2/04 11:06 AM Page 137 138 Screening and Assessment could be indispensable tools for the clinician who is seeking some em- pirical and objective support of medical necessity for managed care ap- proval, especially for inpatient care. Determining the immediacy of short-term suicide risk versus long-term risk is also needed. Many outpatients present ambiguous clinical pictures, requiring the clinician to rely on subjective qualities such as past experience, clinical judgment, and inference in determining the level of risk and the level of care. The SAC and CAQ could offer clarifying, empirically based data, especially when a patient presents with feelings of hopelessness, despair, and/or is significantly depressed. This data in turn would provide docu- mented empirical support for a more accurate diagnosis and could both reduce litigation risks for failing to protect patients from harming them- selves and come closer to establishing a higher “standard of care” (Bon- gar, 1991). Litigation claims of negligence are also reduced by the use of extended assessment beyond the use of the clinical interview alone. As the length of inpatient stays are reduced and as managed care de- mands more “objective” measures in support of treatment plans, the SAC and CAQ could provide a valuable clinical measure of the patient’s current emotional and behavioral stability (or Vital Balance). Fre- quently, retroactive denials of reimbursement can occur because the pa- tient’s chart fails to document medical necessity. If the SAC and CAQ are readministered on a regular basis during inpatient admission and if their scores indicate ongoing suicide risk, this would provide valuable pertinent support for the necessity of continued care. Repeated adminis- tration of the SAC can also help evaluate change in the patient’s level of functioning and can be useful in formulating further treatment plans and ultimate disposition. Repeated evaluation during inpatient stays is also important considering the need for suicide precautions, the privilege of giving passes outside the hospital, as well as for eventual discharge. The SAC and CAQ are not difficult to administer once qualified clin- ical psychologists have been trained, and such assessment makes them valuable for emergency psychiatric services, inpatient nursing staff, and office-based mental health professionals, all of whom need an em- pirically based, quantified database for decision making. The time for completing a SAC and CAQ will vary, dependent on data from the FCI, but should not take more than 30 or 40 minutes if good rapport has been established. c06.qxd 8/2/04 11:06 AM Page 138 Assessing the Vital Balance in Evaluating Suicidal Potential 139 The SAC and CAQ have been informally tested in clinical settings but not yet formally incorporated into a research study. This field testing has resulted in making some revisions in both instruments. More formal research is needed to further evaluate the utility of these instruments, and this will be done. The experimental design would involve the development of compari- son groups. Such groups would be formed by the clinician by use of a general rating of each person to be interviewed by making an estimate of high, low, or moderate suicide potential based on information in the re- ferral questions. Scores of persons in each of these groups would then be compared with this initial rating to determine if the SAC total scores are consistent with these initial rated impressions. Follow-up audits of se- lected individuals would be carried out to evaluate the degree of validity and reliability of the SAC total scores and how consistent they are with these initial estimates and other related data. There would also be various intergroup and intragroup comparisons, the latter based on the demographic variables of age, sex, education, and so forth, to determine what distinctive clinical patterns might emerge. Another major goal is to determine whether specific SAC items and/or item clusters are consistent with total SAC scorings to allow briefer ver- sions of the SAC to be developed. Emergency room (ER) personnel have often requested a briefer version of the SAC, although brevity usually compromises validity and reliability. One brief version (20 items) of the 60-item SAC has been developed and needs to be further field tested in ER settings. A primary concern is the meaning of intermediate or borderline scores, especially on the SAC, and to what use additional assessment pro- cedures will help clarify this more ambiguous range of scoring. The use of the SAB should play an important role of clarification in such cases by providing a more comprehensive and in-depth assessment in order to in- crease specificity and sensitivity of the assessment process. Establishing predictive validity may be a problem, as effective thera- peutic treatment over time will likely improve a person’s coping abili- ties. Thus, if such persons with high SAC and low CAQ scores do not make another suicide attempt, the initial high SAC score is not necessar- ily invalidated because an effective therapeutic intervention may have made a significant impact in reducing vulnerability, improving the c06.qxd 8/2/04 11:06 AM Page 139 [...]... uncertainty of our present world situation REFERENCES Antonovsky, A (1981) Health, stress and coping San Francisco: Jossey-Bass Beck, A T., Kovacs, M., & Weissman, A (1975) Hopelessness and suicidal behavior Journal of the American Medical Association, 2 34, 1 146 –1 149 Assessing the Vital Balance in Evaluating Suicidal Potential 141 Bongar, B (1991) The suicidal patient: Clinical and legal standards of care... poor social skills Bostock and Williams (19 74) and O’Farrell, Goodenough, and Cutter (1981) have also reported treatment of suicidal clients with behavioral therapy, primarily by reinforcing appropriate behaviors while not reinforcing suicidal behaviors and with the use of behavioral contracts More controversially, Farrelly and Brandsma (19 74) used paradoxical intention with suicidal clients, such as... our understanding of suicidal behavior Because psychoanalysis is a slow process, it is difficult to document the use of its techniques for dealing with suicidal people The goal of psychoanalysis is a thorough exploration of the contents of the conscious and unconscious mind, and this has to proceed slowly for both suicidal and nonsuicidal clients The usefulness of the perspective for suicidal clients... they will be much happier and make appropriate choices 150 Intervention and Treatment of Suicidality Beck’s (1976) cognitive-behavioral therapy is a more recent version of cognitive therapy The goal of cognitive-behavioral therapy is to modify faulty patterns of thinking both directly and indirectly It focuses on clients’ cognitions (thoughts and attitudes) and the assumptions and premises that underlie... Systems of Psychotherapy and Suicidal Behavior 147 relocated in the ego, and used to re-create the loved one as a permanent feature of the self in an identification of the ego with the lost object Litman (1967) called this process ego-splitting Even before becoming suicidal, the person has probably already introjected some of the desires of the loved one Children introject desires of their parents, and. .. 140 Screening and Assessment person’s coping abilities, thereby allowing improved management and adaptation to future stressful situations and significantly decreasing the likelihood of future self-destructive or self-harm behaviors It is hoped that a more detailed analysis of the assessment characteristics of the SAC and CAQ might also allow for the assessment of longer term risk of self-destructive... Intervention and Treatment of Suicidality CHAPTER 7 The Classic Systems of Psychotherapy and Suicidal Behavior David Lester In many discussions of counseling for suicidal clients, the level of analysis does not proceed much beyond the training given to nonprofessional crisis counselors working at suicide prevention centers, training that focuses on active listening (person-centered therapy), assessment of resources,... modifying dysfunctional 158 Intervention and Treatment of Suicidality patterns of thinking or undertaking a psychoanalytic exploration of the client’s conflicts Suicidal clients may thus be able to make use of all of the techniques discussed herein to leave the abyss of despair (A good example is the work of Meech and Wood [2000] with a suicidal 12-year old with a history of severe childhood privation They... Classic Systems of Psychotherapy and Suicidal Behavior 161 Reynolds, D K (19 84) Morita therapy and suicide prevention Crisis, 5, 37 44 Richman, J., & Eyman, J R (1990) Psychotherapy of suicide In D Lester (Ed.), Current concepts of suicide (pp 139–158) Philadelphia: Charles Press Rogers, C R (1959) A theory of therapy, personality, and interpersonal relationships, as developed in the client-centered framework... cognitive model of suicidal behavior In D Lester (Ed.), Current concepts of suicide (pp 1–28) Philadelphia: Charles Press Ingram, J K., & Hinkle, J S (1990) Reality therapy and the scientist Journal of Reality Therapy, 10(1), 54 58 Janov, A (19 74) Further implications of “level of consciousness.” Journal of Primal Therapy, 1, 193–212 Jansson, L (19 84) Social skills training for unipolar depression Scandinavian . Press. c06.qxd 8/2/ 04 11:06 AM Page 141 c06.qxd 8/2/ 04 11:06 AM Page 142 PART TWO Intervention and Treatment of Suicidality c07.qxd 8/2/ 04 11:05 AM Page 143 c07.qxd 8/2/ 04 11:05 AM Page 144 145 CHAPTER. preoccupation and behavior. Many of the papers by psychoanalysts on suicidal behavior, particu- larly on the motivations involved and on the problems of countertransfer- ence in psychotherapy with suicidal. c07.qxd 8/2/ 04 11:05 AM Page 146 The Classic Systems of Psychotherapy and Suicidal Behavior 147 re located in the ego, and used to re-create the loved one as a permanent feature of the self in